reporting their activities to the public. Yet, as
ing services.
will be explained in detail below, boards rely
on private organizations for much of their
Disciplining Poor Performers?
credentialing activity, disciplinary efforts are
Discipline is the second task of state medical
largely ineffective, and consumers receive lit-
boards and takes up most of the time of board
tle information from licensing boards that
staff. Disciplinary efforts generally focus on
helps them choose quality clinicians. It is
resolving complaints filed by the general public.
legitimate to ask, what value does licensing
When state board members and managers of
add?
state board disciplinary efforts were surveyed in
20042005, however, they expressed the con-
Checking Credentials
cern that public complaints are not a good indi-
cator of serious problems with practitioners.51
State boards establish education and train-
Those surveyed felt that physicians, nurses, hos-
ing criteria (including post-graduate training)
pitals, and other providers would provide better
and require potential licensees to pass exami-
leads. Yet medical professionals tend to under-
nations to test their knowledge and skills. State
report quality problems. According to one sur-
boards also fingerprint applicants, checking
vey: "Forty-five percent of [physicians] with
criminal records with the Department of
direct personal knowledge of a physician in
Justice and the Federal Bureau of Investigation.
their hospital group or practice who was
Credential verification and background checks
impaired or incompetent did not always report
account for a sizable share of state medical
board spending.49
that physician. Of those with direct personal
State medical boards don't do all the work
knowledge of a serious medical error, 46 percent
themselves. They rely heavily on private organi-
did not report that error to authorities on at
least 1 occasion."52 Moreover, those who did
zations that accredit education and training
report problem colleagues did not necessarily
programs and credential individual clinicians.
report them to a state medical board. Thus
For example, unique state tests for physicians
there are potentially many serious quality prob-
have given way to common national test, the
lems that licensing cannot even identify, much
United States Medical Licensing Examination
less remedy. Indeed, state medical boards "typi-
(designed and administered by two indepen-
cally do not define prevention of injury as part
dent, private organizations: the Federation of
of their responsibility."53
State Medical Boards and the National Board of
A second problem confronting state
Medical Examiners). To assess physician train-
boards is that it is very difficult and expensive
ing, all states rely on the American Medical
to establish substandard care, incompetence,
Association's accreditation of U.S. medical
or negligence.54 Expert witnesses and lawyers
schools.
are expensive. State boards don't have suffi-
Likewise, states depend on the Accreditation
cient time or money to investigate the large
Review Commission on Education for the
number of malpractice settlements and judg-
Physician Assistant to assess training programs
ments.55
for physician assistants and on the National
As a result, state boards have a poor record
Board for Certification of Occupational
of disciplining errant physicians. A study of
Therapists' examination to assess the skills of
Florida physicians with malpractice payouts
occupational therapists. Many states rely on the
over $1 million found that only 16 percent
American Nurses Credentialing Center, which
had been sanctioned by the state medical
credentials individuals across 26 categories of
State boards have
board.56 Among physicians who made 10 or
nurses and nurse practitioners (advanced prac-
a poor record of
tice nurses).50 These are just a few of the outside
more malpractice payments between 1990
organizations on which states rely. In the
and 2005, only one-third were disciplined by
disciplining
their state boards.57
absence of licensing laws, these organizations
errant physicians.
Further complicating the disciplinary
would continue to provide valuable credential-
7